**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility provided policies and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to protect residents from staff-initiated abuse and/or neglect. This failure resulted in a staff member physically abusing a resident and multiple staff neglecting care of 18 of 184 residents reviewed. This failure created an Immediate Jeopardy situation for 18 of 184 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. The policy further defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect was defined as the failure of the facility, its employees or services providers to roved goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 8/3/23, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and osteoporosis (condition when the bones become brittle and fragile). Review of Section C: Cognitive Patterns revealed Resident R1 to be severely cognitively impaired. Review of Section D: Behavior indicated that Resident R1 is known to have behavioral symptoms. Review of Resident R1 ' s care plan for behavior problems initiated 10/21/22, included the intervention for staff to approach and speak in a calm manner. Review of a progress note written by Registered Nurse (RN) Employee E12 dated 9/13/23, at 6:56 p.m. indicated Was informed of an incident at 5:30 of an incident by the Unit Manager (Employee E22), that there was an incident involving RN Employee E1 and Resident R1. RN Employee E1 was sent home, 911 was called at 5:50 p.m. Review of facility submitted information dated 9/14/23, indicated that on 9/13/23, Nurse Aide (NA) Employee E2 reported that RN Employee E1 had called Resident R1 a bitch and moved around the desk towards the resident. NA Employee E2 stepped between the resident and the nurse. No physical contact occurred between the nurse and the resident. Review of an employee statement written by RN Employee E1 dated 9/13/23, indicated This RN was at nurse's station trying to get the two residents apart from one another. We (staff) had been trying this for a length of time and the two were not moving/separating. I was telling them to go to their rooms or the dining room and Resident R1 grabbed the pen from my hand and threw it at me. I then went from behind the desk to get them to move. The NA thought I was going to harm the resident, but I was attempting to get her to move from the nurse's station. I did mumble under my breath and called her a bitch. Resident was never touched or harmed. Staff continued to work to get them apart. They then moved to the dining room. NA Employee E2 went downstairs to find supervisor. I did tell NA Employee E2 my supervisor was (the Director of Nursing). NA Employee E2 did not contact (the DON), however she did tell Licensed Practical Nurse Employee E15 that she recorded the abuse stated on her phone. She was also recording other staff while in the dining rooom that were addressing the two residents. Review of an undated employee statement written by NA Employee E2 indicated While sitting at the nurse's station I began to hear Resident R1 become upset about being alone with Resident R54. The Unit Manager (UM - RN Employee E1) began to explain why she couldn't and Resident R1 started getting more frustrated, the UM became angry and started to yell back in a mean tense. At this moment I became concerned, and recorded for my resident's safety as well as myself. The UM called the resident a little bitch and charged towards (Resident R1) as if she wanted to hit her. At this moment I stepped in between and let the UM know she was out of line and to remember she was on a dementia unit. I also stated that she needed to apologize to the resident. I asked her if she had another supervisor present, and I went to speak with him. I felt unsafe for my resident, the UM apologized but that shouldn't have occurred. I understand recording is not permitted, but needed to be able to support my statement. Review of an employee statement written by NA Employee E3 dated 9/13/23, indicated I was the one-on-one with Resident R54 when issue happened. I was standing between Resident R1 and Resident R54. Resident R1 was not listening (to) me and (NA Employee E4) both kept redirecting Resident R1 to go back to dining room and sit down she was not easily redirected at all. RN Employee E1(UM) heard us having a hard time came out her office to redirect Resident R1. Resident R1 then grabbed her pen out of her and hit RN Employee E1(UM) in the face with it. Yes, RN Employee E1(UM) did call her a little bitch but it wasn't loud she kinda muttered it. She was a little angry at the situation but we know she would never put her hand on any resident. RN Employee E1 (UM) also wanted NA Employee E2 to come talk in her office and she wouldn't go. NA Employee E2 started scolding RN Employee E1(UM) like she was a child. Review of an employee statement written by NA Employee E4 dated 9/13/23, indicated NA Employee E3 was standing in between Resident R54 and Resident R1 trying to get her to go into the dining room. Resident R1 kept getting angrier and we kept trying to redirect her. RN Employee E1 (UM) came over and told her to go to her room or go sit in the dining room. Resident R1 grabbed the pen out of RN Employee E1's (UM) hand and threw it at her and hit her in the face. RN Employee E1(UM) came from behind the desk. NA Employee E2 stared scolding RN Employee E1(UM) like she was a little child. RN Employee E1 (UM) asked her to go into her office and talk but she wouldn't go. NA Employee E2 was being very unprofessional. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and a seizure disorder. Review of Section C revealed Resident R2 to be cognitively intact. Review of Section H - Bladder and Bowel revealed that Resident R2 is occasionally incontinent. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section C revealed Resident R3 to be cognitively intact. Review of Section G: Activities of Daily Living (ADL) Assistance indicated Resident R3 required staff assistance for bed mobility, toilet use, and personal hygiene. Resident R3 ' s care plan for ADL assistance initiated 5/17/23, indicated Resident R3 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and an anoxic brain injury (injury to the brain caused by a complete lack of oxygen). The facility diagnosis list included Review of Section C revealed Resident R4 to be moderately cognitively impaired. Review of Section G: indicated Resident R4 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R4 is always incontinent of bladder and bowel. Review of Resident R4 ' s care plan initiated 12/21/21, and revised on 9/21/23, revealed that he has impaired cognitive function, and the care plan for incontinence revised on 11/15/22, revealed that Resident R4 should be checked for incontinence and for his brief to be changed as needed. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Section C revealed Resident R5's BIMS score to be 12, moderately cognitively impaired. Review of Section G: indicated Resident R5 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R5 is frequently incontinent of bladder and bowel. Review of Resident R5 ' s care plan initiated 7/26/23, revealed that she has impaired cognitive function, and the assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression) and a seizure disorder. Review of Section C revealed Resident R6 to be moderately cognitively impaired. Review of Section G indicated Resident R6 required staff assistance for bed mobility, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R6 is always incontinent of bladder and bowel. Resident R6 ' s care plan for ADL assistance initiated 5/17/23, indicated Resident R6 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of Resident R6 ' s care plan for incontinence initiated 7/19/21, revealed that Resident R6 should be checked for incontinence and that briefs should be changed as needed. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain) and diabetes. Review of Section C revealed Resident R7 to be moderately cognitively impaired. Review of Section G indicated Resident R7 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R7 has a urinary catheter and is always incontinent of bowel. Resident R7 ' s care plan for bowel incontinence initiated 7/13/23, indicated for staff to provide assistance as needed, and to provide peri-care (cleaning the genitalia and surrounding area) after each incontinent episode. Review of the clinical record indicated Resident R8 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of a seizure disorder and history of a stroke. Review of Section C revealed Resident R8 to be moderately cognitively impaired. Review of Section G indicated Resident R8 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R8 is always incontinent of bladder and bowel. Resident R8 ' s care plan for ADL assistance initiated 2/21/23, revealed Resident R8 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R8 ' s care plan for bowel incontinence initiated 2/28/23, indicated for staff to provide assistance as needed, and to provide peri-care (cleaning the genitalia and surrounding area) after each incontinent episode. Review of the clinical record indicated Resident R9 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and osteoporosis (condition when the bones become brittle and fragile). Review of Section C revealed Resident R9 to be severely cognitively impaired. Review of Section G indicated Resident R9 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R9 was frequently incontinent of bladder and bowel. Resident R9 ' s care plan for ADL assistance initiated 5/12/23, revealed Resident R9 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R9 ' s care plan for bladder incontinence initiated 5/22/23, revealed staff should check resident for incontinence. Wash, rinse, and dry perineum. Change clothes as needed after incontinent episodes. Change briefs as needed. Review of the clinical record indicated Resident R10 was admitted to the facility 10/10/19. Review of the MDS dated [DATE], included diagnoses of atrial fibrillation and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C revealed Resident R10 to be severely cognitively impaired. Review of Section G indicated Resident R10 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R10 is frequently incontinent of bladder and bowel. Resident R ' s care plan for ADL assistance initiated 7/1/21, revised 1/30/23, revealed that staff should observe and anticipate Resident R10 ' s needs: food, thirst, body positioning, pain, and toileting needs. Resident R10 ' s care plan for bowel incontinence initiated 8/5/22, revealed that staff should provide peri-care after each incontinence episode. Resident R10 ' s care plan for bladder incontinence initiated 8/5/22, staff should check Resident R10 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R11 was admitted to the facility 3/10/23. Review of the MDS dated [DATE], included diagnoses of COPD and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Section C revealed Resident R11 to be moderately cognitively impaired. Review of Section G indicated Resident R11 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R11 is always incontinent of bladder and bowel. Resident R11 ' s care plan for ADL assistance initiated 6/15/23, revealed Resident R11 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R11 ' s care plan for bowel incontinence initiated 3/21/23, revealed that staff should provide peri-care after each incontinence episode. Resident R11 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R12 was admitted to the facility 5/31/23. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R12 to be cognitively intact. Review of Section G indicated Resident R12 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R12 is frequently incontinent of bladder and bowel. Resident R12 ' s care plan for ADL assistance initiated 6/1/23, revealed Resident R12 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R12 ' s care plan for bowel incontinence initiated 6/5/23, revealed that staff should provide peri-care after each incontinence episode. Resident R12 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R12 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R13 was admitted to the facility 1/14/23. Review of the MDS dated [DATE], included diagnoses of chronic kidney disease (gradual loss of kidney function) and dementia. Review of Section C revealed Resident R13 to be severely cognitively impaired. Review of Section G indicated Resident R13 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R13 is frequently incontinent of bladder and bowel. Resident R12 ' s care plan for ADL assistance initiated 1/16/23, revealed Resident R13 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R13 ' s care plan for frequent bowel incontinence initiated 1/23/23, revealed that staff should provide peri-care after each incontinence episode. Resident R11 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode Review of the clinical record indicated Resident R14 was admitted to the facility 11/22/22. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R14 to be moderately cognitively impaired. Review of Section G indicated Resident R14 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R14 is always incontinent of bladder and bowel. Resident R14 ' s care plan for history of a cerebral vascular accident (CVA, stroke) initiated 12/5/22, revealed staff should assist with ADL and provide passive range of motion with care. Resident R14 ' s care plan for bowel incontinence initiated 12/5/22, revealed that staff should provide peri-care after each incontinence episode. Resident R14 ' s care plan for bladder incontinence initiated 8/5/22, staff should check Resident R14 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility staffing information indicated that NA Employee E5 was responsible for ADL care for Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14. Review of a report dated 10/2/23, indicated the local police were dispatched to the facility and they had been called by the facility to report neglect. The Director of Nursing (DON) provided the officer with four sworn statements dated 10/1/23. The DON also provided a list of highlighted patients (Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) that were named in the allegation. Review of an employee statement written by Licensed Practical Nurse (LPN) Employee E6, this nurse expressed concerns with the nursing supervisor throughout the shift. This NA (NA Employee E5) was missing for over 30 minutes. The call lights were going off. The nursing supervisor made an announcement. The NA sat at the nursing station. This nurse encouraged this NA to change the resident. The NA kept disappearing. The NA was asked to do walking rounds. The NA was late. The residents were complete [sic]. NA Employee E5 told this nurse she could not get residents up because of it by six hoyers. Review of an employee statement written by RN Employee E7 indicated that the B-1 unit 3:00 pm to 11:00 p.m. aide and the assigned nurse for 7:00 a.m. to 7:00 p.m. reported NA Employee E5 who worked that none of the residents were changed and all the residents were soaked, and their briefs were torn due to excess voiding. 3:00 pm to 11:00 p.m. aide had to change every bed also. Review of an employee statement written by LPN Employee E8 indicated .had (list of room numbers) on the 3:00 p.m. to 11:00 p.m. shift .whoever was the 7:00 a.m. to 3:00 p.m. daylight aid did not do no last rounds at all. Resident R4 was laying in his own BM (bowel movement) it was everywhere from his head to feet covered in his own BM. Resident R5 was wet with old urine ring stains in the sheets. Resident R6 was soaking wet in urine. Resident R7 was sitting wet in urine. Resident R9 was soaking wet in urine. Resident R11 was soaking wet, also Resident R12. Everyone total bed changes with old urine rings on the sheet. Review of an employee statement written by NA Employee E5: I didn't get some up because one of them refused. It was only three people and a busy day so I couldn't get help with Hoyer for all six people. For the people I didn't change in the afternoon I got a really bad pain in my knee from slipping in the shower room the previous day. It got so bad to the point I couldn't move but I tried my best to finish up it just got unbearable, and I didn't want to go home and leave only two aides on the floor. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not provide care to her unit (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14). NA Employee E5 confirmed she did not previously inform facility staff of her injury on 10/1/23, that she stated prevented her from providing care. NA Employee E5 confirmed she did not inform facility management or a charge nurse on 10/2/23, that she was unable to provide care, and that multiple of her residents were left in soiled briefs, clothing, and linen. The facility failed to remove this aide from the schedule until further investigations were completed putting these residents at risk for continued neglect. Review of the clinical record indicated Resident R15 was admitted to the facility 7/3/23. Review of the MDS dated [DATE], included diagnoses of obstructive uropathy (condition where the flow of urine is blocked), reduced mobility, and the need for assistance with personal care Review of Section C revealed Resident R15 to be cognitively intact. Review of Section G indicated Resident R15 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R15 has a urinary catheter and is always frequently of bowel. Resident R15 ' s care plan for ADL assistance initiated 7/5/23, revealed that Resident R15 is extensive to total assistance with toileting and that Resident R15 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R15 ' s care plan for bowel incontinence initiated 7/5/23, revealed that staff should provide peri-care after each incontinence episode. Review of facility submitted information dated 10/3/23, indicated that on 10/3/23, Resident R15 stated that the NA on the 3:00 p.m. - 11:00 p.m. shift had yelled at her because she had to call her back into the room after an incontinent episode. Resident R15 stated that the NA was very rough with her. Resident stated that her vagina was still burning and sore hours after the incident. Review of a progress note dated 10/4/23, at 12:34 p.m. indicated Resident assessed with LPN Employee E23, resident was incontinent of BM, cleaned, new brief applied. Resident's peri/ buttocks are excoriated, bright red, multiple wounds present. No new wounds were noted. Review of a transcribed employee statement to the DON from NA Employee E9 on 10/4/23, indicated, Took care of Resident R15 last night every time you clean her up, she is in pain. I was not being rough with her on the way out she offered me candy. Am I being rough with her, no I am not. Review of an employee statement written by NA Employee E10 dated 10/4/23, indicated Resident R15 called me into the room at 11:30 p.m. and asked to be changed because the aide before (NA Employee E9) didn't clean her well enough. While I was helping her, Resident R15 began to tell me what NA Employee E9 did to her. Resident R15 called NA Employee E9 into the room the first time because Resident R15 needed a blanket and Employee E9 obliged her. About five minutes later Resident R5 put her call light on again because she moved her bowels and asked to be changed and Resident R15 stated that NA Employee E9 screamed at her and while she (NA Employee E9) was attempting to clean her up, scrubbed Resident R15's vagina so roughly that she hurt hours after the fact. Resident R15 waited until 11:30 p.m. to put on the call bell again because she wanted to make sure that NA Employee E9 wasn't in the facility. Review of an employee statement written by LPN Employee E24 dated 10/4/23, indicated NA Employee E10 made this nurse aware at 11:30 p.m. that resident wanted to speak to me. Resident told this nurse that NA Employee E9 on 3:00 p.m. - 11:00 p.m. had yelled at her because she had to call her back into the room after an incontinent episode. She stated that NA Employee E9 was very rough with doing her incontinence care. She stated her vagina was still burning and sore hours after incident. Resident had waited to report this incident until after 11:00 p.m. when she knew NA had left. She staed that she had never been treated so roughly. She said that she had called the main number of the facility but was not able to get anyone to give me the message that she needed me to help. NA Employee E10 provided incontinence care at this time. Resident positioned for comfort. RN Supervisor made aware of incident. During an interview on 11/9/23, at 11:00 a.m. Resident R15 described the incident. It was about nine (9:00 p.m.) I asked NA Employee E9 to cover me with a blanket. Right after, I needed to be changed. She yelled and screamed at me, she hurt me when she was changing me. After that the man aide (NA Employee E10) took good care of me and cleaned me up. When asked if she felt scared, Resident R15 responded, Oh, yeah. It was an assault. Definitely was. When she stuck her hand in between my legs so hard, I was hurting for a couple days. It was painful what she did to me. Seemed like she was ready to kill me. It was really nasty. Review of the clinical record indicated Resident R16 was admitted to the facility 12/14/21. Review of the MDS dated [DATE], included dementia and high blood pressure. Review of Section C revealed Resident R16 to be severely cognitively impaired. Review of Section G indicated Resident R16 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R16 is always incontinent of bladder and bowel. Resident R16 ' s care plan for bowel incontinence initiated 12/27/21, revealed that staff should provide peri-care after each incontinence episode. Resident R16 ' s care plan for bladder incontinence initiated 12/27/21, staff should check Resident R16 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility submitted information dated 10/5/23, indicated that on 10/5/23, at 2:00 p.m. Resident R16 was moved from one wing of the facility to a different wing. He was noted with a ring of wet urine on the fitted sheet with a dry brief. Review of a progress note written by RN Employee E12 dated 10/5/23, at 5:55 p.m. indicated Resident had urine-soaked bed, resident sound asleep, no injuries noted. Resident and resident's bed changed. Review of an employee statement written by LPN Employee E25 on 10/5/23, indicated Nurse aides reported that when patient (Resident R16) one wing to the other, he was noted with a round ring, wet fitted sheet with dry brief. Review of an employee statement written by NA Employee E26 on 10/5/23, indicated Resident R16 came downstairs after being upstairs for a few days and his bed was dirty with a big dirty ring around the butt area and the brief was dry. Review of an employee statement written by NA Employee E11 on 10/5/23, indicated I never got the chance to wash and change Resident R16 yet because I had showers to do this morning. I'm always on the back of (unit) everyday and it's heavy and don't nobody want to work back so I'm stuck working back there every day. I was going to change and wash him after lunch before he went downstairs. Review of the clinical record indicated Resident R17 was admitted to the facility 6/3/22. Review of the MDS dated [DATE], included psychotic disorder (mental disorder characterized by a disconnection from reality) and intellectual disabilities. Review of Section C revealed Resident R17 to be severely cognitively impaired. Review of Section G indicated Resident R17 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R17 is always incontinent of bladder and bowel. Resident R17 ' s care plan for bladder incontinence initiated 6/15/22, revealed staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility submitted information dated 10/11/23, indicated that on 10/10/23, at 11:30 p.m. NA Employee E14 stated that on 10/10/23, at 6:30 a.m. he had written the date, time, and his initials on Resident R17's brief. When NA Employee E14 came on duty on 10/10/23, at 11:30 p.m. he went to change Resident R17's brief which still had on the date, time, and his initials. Review of facility staffing information indicated that NA Employee E5 was responsible for Resident R17's care on 10/10/23, day shift; NA Employee E14 was responsible for Resident R17's care on 10/10/23, evening shift, Review of an employee statement written by NA Employee E14 on 10/10/23, at 11:30 p.m. indicated Resident is consistently overly saturated. Date, timed, and initial briefs for 10/10/23, at 6:30 a.m. when resident was changed on last rounds. Came in tonight to resident stating My pee-pee hurts and asked to change him he complied. Pulled the same brief off that I put on. Let the nurse know, went and got supervisor, advised her of it. Supervisor did ask me why I was dating briefs, to cause problems. I stated no, it's because residents are being abused and neglected. Supervisor escalated to DON. Review of an employee statement written by NA Employee E5 on 10/11/23, indicated Resident R17 did not get changed because he was already irritated and screaming and yelling when I asked him, he started to scream and yell more and left unit. Review of an employee statement written by LPN Employee E27 on 10/11/23, indicated Around 8:30 p.m. NA Employee E28 approached this nurse and said that resident was refusing to be changed and put in bed and was barricading himself inside the dining room. Resident was in the dining room at the end of shift. Review of behavior charting completed by NA Employees E5 and E13 both documented that Resident R17 had not displayed behaviors on 10/10/23. Review of a progress note written by RN Employee E12 dated 10/11/23, at 6:01 p.m. indicated Resident assessed post complaint from previous shift. Peri area is reddened with two open areas, right groin and left lower groin area. Resident also has reddened areas under breast folds, red and yeast like. Resident's thighs and lower legs are also reddened. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not provide incontinence care to Resident R17 on 10/10/23. When asked the reason why, she stated that Resident R17 had been displaying behaviors that day. NA Employee E5 confirmed that she had documented Resident R17 as having no behaviors, as this level of behavior was his normal. NA Employee E5 was unable to explain why, if this level of behavior is normal, he is able to be provided incontinence care[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility provided policies and documentation, provided reports, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. The policy further stated the facility will provide education and training upon hire, annually, and as needed for retraining. Education and training in-services documentation of attendance will be maintained. Review of a facility submitted report dated 9/14/23, indicated that on 9/13/23, Nurse Aide (NA) Employee E2 reported that RN Employee E1 had called Resident R1 a bitch and moved around the desk towards the resident. NA Employee E2 stepped between the resident and the nurse. No physical contact occurred between the nurse and the resident. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property completed 9/19/23, indicated verbal abuse was substantiated. Review of facility provided education sign-in sheets dated 9/21/23, 63 staff members of the 200 staff current at the time of the education, who remained employed at the facility at the time of the survey, were documented as having received education. Review of a provided report dated 10/2/23, indicated the local police were dispatched to the facility, after the facility had called to report an allegation of abuse/neglect. The Director of Nursing (DON) was noted to have provided provided the officer with four sworn statements dated 10/1/23. The DON also provided a list of highlighted patients. These statements alleged neglect of Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14 by Nurse Aide (NA) Employee E5. A facility submitted report and a Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property were not completed. Review of a facility submitted report dated 10/4/23, indicated that on 10/3/23, Resident R15 stated that the NA (NA Employee E9) on the 3:00 p.m. - 11:00 p.m. shift had yelled at her because she had to call her back into the room after an incontinent episode. Resident R15 stated that the NA was very rough with her. Resident stated that her vagina was still burning and sore hours after the incident. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E9 completed 10/4/23, indicated the investigation was ongoing. Review of NA Employee E9's personnel file on 11/4/23, indicated that NA Employee E9 was terminated from employment at the facility, related to substantiated abuse. Review of a facility submitted incident dated 10/5/23, indicated that on 10/5/23, at 2:00 p.m. Resident R16 was moved from one wing of the facility to a different wing. He was noted with a ring of wet urine on the fitted sheet with a dry brief. NA Employee E11 was immediately suspended. A Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property was not completed. Review of the education provided for the above-mentioned incident on 9/13/23, failed to include reeducation for the alleged perpetrators NA Employee E5 (10/2/23), NA Employee E9 (10/3/23), and NA Employee E11 (10/5/23). Review of facility provided education sign-in sheets dated 10/2/23, through 10/6/23, 64 staff members of the 214 staff current at the time of the education, who remained employed at the facility at the time of the survey, were documented as having received education. Review of a facility submitted incident dated 10/11/23, indicated that on 10/10/23, at 11:30 p.m. NA Employee E14 stated that on 10/10/23, at 6:30 a.m. he had written the date, time, and his initials on Resident 17's brief. When NA Employee E14 came on duty on 10/10/23, at 11:30 p.m. he went to change Resident R17's brief which still had on the date, time, and his initials. Review of facility staffing information indicated that NA Employee E5 was responsible for Resident R17's care on 10/10/23, day shift; NA Employee E13 was responsible for Resident R17's care on 10/10/23, evening shift. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E5 completed 10/11/23, indicated the investigation was ongoing. A Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E13 was not completed. Review of NA Employee E5's personnel record included a corrective action. Employee had a report of neglect (this is the 2nd report of this since the start of employment). The investigation was unsubstantiated but this employee will be brought back to work and will need to complete her Relias (electronic educational program) to 100% and will be retrained by a senior aide. Suspended 10/12/23, and 10/13/23, back to work on 10/16/23. Review of the facility reeducation provided to NA Employee E5 after this second incident (10/2/23, 10/11/23) included: Bathing, urinary drainage bag maintenance, care of indwelling urinary catheter care, skin check, and shaving - electric razor. During an interview with NA Employee E34, responsible retraining NA Employee E5, on 11/5/23, at 5:13 p.m. NA Employee E34 confirmed that she provided hands-on reeducation on how to change a brief, hand-washing, and other hands-on care issues. When asked if she felt NA Employee E5 needed retraining, NA Employee E34 responded, Absolutely needed retraining. Even when I retrained her, she was having a rough time to be involved in the care. Maybe she didn't want to do it, maybe she was uncomfortable. It didn't seem like she cared or was getting it. Further review of facility provided investigation documentation failed to include reeducation on abuse or neglect for NA Employee E5 related to the incident on 10/11/23. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not received in-person abuse and neglect retraining based on the 10/2/23, and 10/11/23, incidents. Review of a facility submitted report dated 11/5/23, indicated that on 11/5/23, at 6:00 a.m. Resident R18 was found to have a bedpan underneath her for an unknown amount of time. Evening shift staff stated that a bedpan had been placed under Resident R18 at approximately 7:00 p.m. on 11/4/23. The assigned nurse aide stated that she checked when Resident R18 wasn't sure if there was a bedpan underneath her or that she might be dreaming. The nurse aide put her hand underneath Resident R18's left buttock and between her legs and did not feel a bedpan. The nurse aide didn't completely roll the resident to check. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for LPN Employee E29 initiated 11/5/23, indicated the investigation was ongoing. During an interview on 11/7/23, at 11:00 a.m. the Nursing Home Administrator stated that for the above incidents, facility staff education was completed at 100% due to a text blast that included all facility staff members. The Nursing Home Administrator confirmed that while it could be verified that the education was sent out via text message to all employees, there was no capability or process in place to ensure that the receiving staff member opened, read, or understood the education. On 11/7/23, at 11:04 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed and the Immediate Jeopardy template was provided to facility administration. On 11/7/23, at 5:24 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -Ad hoc QAPI (Quality Assurance and Performance Improvement) will be conducted by facility QAPI committee to report allegations of noncompliance during the survey on 11/7/23. -RDO will provide abuse education to facility leadership, including a posttest. Facility leadership will administer same education and posttest to employees and contracted employees of the facility. This will be completed by 11/7/23. -Any employee that is not available to come into the facility will be educated regarding abuse over the phone and will not be permitted to return to the active work schedule until they come into the facility and satisfactorily complete the posttest. -The front desk of the facility will be staffed by facility, leadership around the clock to ensure compliance with education for all employees unable to come to the facility on [DATE]. -Random skin sweeps and abuse questionnaires on five residents five times a week for the next two weeks and weekly for eight weeks of the residents of the facility by the DON/designee. -Random education audits will be conducted by the employees utilizing the same abuse posttest to ensure retention of knowledge. This will be contacted with 10 staff members five times a week for the next two weeks and weekly, eight for eight weeks of the employees of the facility by the DON/designee. -Additional abuse education will be completed monthly for three months to be completed by the DON/designee. Compliance will be monitoring and ensuring completion of this education will be done by the HR manager/designee. -Facility will reach out to (directed in-service provider) regarding the scheduling of a directed in-service for all employees and contracted employees of the facility. This will be scheduled with (directed in-service provider) within the next 30 days. -All abuse training will be certified complete by the HR manager/designee against an active employee/ contracted employee roster, starting at 11/7/233 and ongoing. -All findings regarding the IJ citation reported monthly in the facility's QAPI meeting for the next three months. During observations completed on 11/8/23, between 9:30 a.m. and 4:00 p.m. the Director of Nursing was observed providing confirmatory education to staff who had received education via telephone, and education to agency staff prior to the start of the shift. During staff interviews conducted on 11/8/23, between 9:30 a.m. and 4:00 p.m. 25 staff members confirmed they received education on abuse prevention. During staff interviews conducted on 11/9/23, between 9:30 a.m. and 11:30 a.m. 16 staff members confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 11/9/23, at 11:55 a.m. when the action plan implementation was verified. During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, resident interviews, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 176 residents (Resident R1). Findings include: Review of facility policy Elopement Prevention reviewed 10/18/22, indicated that elopement is defined as when a resident leaves the premises or a safe area without authorization and/or a supervision and places the resident at harm or risk for injury. Any resident admitted who is cognitively impaired and can self-ambulate is considered an elopement risk until determined otherwise. Review of the clinical face sheet indicated that Resident R1 was admitted on [DATE]. A review of the Minimum Data Set Assessment (MDS-periodic assessment of care needs) dated 4/23/23, included diagnoses of cerebrovascular accident (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain burst), cognitive social or emotional deficit (problems with the ability to think, learn, remember, use judgement, and make decisions and an inability to regulate their responses to certain emotions) and cognitive communication deficit (difficulty with thinking and how someone uses language). Review of medical record revealed a document dated 4/30/18, from the Court of Common Pleas, Orphans ' Court Division, that was entitled Final Order of Court Determining Incapacity and Appointing Plenary Guardian of the Person and/or Estate. This document awarded guardianship to Resident R1's aunt (Resident Representative) based on, but not limited to, the following statement: Resident R1 suffers from vascular cognitive disorder, stemming from a brain aneurysm rupture on May 17, 2017, a condition or disability which totally impairs her capacity to receive and evaluate information effectively and to make and communicate decisions concerning her management of financial affairs or to meet essential requirements to her physical health and safety. Review of Resident R1's medical record revealed a Care Plan initiated 7/1/21, for behavior problems that included removing her roommate's oxygen and throwing it on the floor, approaching other residents with a closed fist, unfastening other resident clothing, collecting other residents' food and drinks from their rooms, taking food out of the nourishment room, trying to smoke in the facility, inappropriate sexual behaviors towards other residents and staff (e.g. smacks staff on the buttocks), and entering other rooms without invitation and will take items. Review of medical record revealed a physician's order dated 1/27/22, that stated Resident R1 may not go out on LOA (leave of absence) with anyone unless approved by guardian. Review of Resident R1's medical record revealed a progress note dated 3/8/22, that stated Resident R1 was noted at bedtime going into patients' rooms, and noted going into resident room bathrooms this shift as well. Patient redirected multiple times. Review of Resident R1's medical record revealed an additional progress note dated 3/23/22, that stated Resident R1 was walking halls, and went into the lounge and was witnessed attempting to open a beg left in there. She was stopped, educated, and redirected. Review of Resident R1's physician orders dated 4/19/22, to apply Wanderguard (a monitoring device worn on the wrist or ankle that alerts staff when a resident leaves a safe area.) Review of Resident R1's care plan initiated 4/20/22, for elopement risk, with goal that Resident R1 will not exit property if unsafe to navigate community. Review of the Wandering Observation Tool, (an assessment meant to determine risk of resident wandering or eloping) for Resident R1, dated 8/23/22, contained the following information: 1) Does resident have a history of wandering and /or a pattern tied to the resident ' s past? Yes 2) Is the resident accepting of current stay/living arrangements? Yes 3) Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave? Yes 4) Has the resident expressed anxiety/apprehension to leave the facility, packed personal belongings, pacing with no course of action or direction, or attempted to exit doors? Yes 5) Does the resident have a history of elopement? Yes 6) Does the resident wander without a sense of purpose? (i.e., confused, may enter others ' rooms, and explore other ' s belongings? Yes 7) Does resident have any additional risk factors for elopement or unsafe wandering? No 8) Based on the responses above, is the resident at risk for elopement or unsafe wandering? Yes Based on this evaluation, the resident has been identified as a risk for elopement or unsafe wandering, proceed to care plan. Further review of Resident R1's medical records and subsequent Wandering Observation Tool assessments dated 11/23/22, and 2/24/23, contained similar content, but all concluding with the statement, Based on this evaluation, the resident has been identified as a risk for elopement or unsafe wandering, proceed to care plan. Review of a nurses note for Resident R1 written on 5/4/23, at 6:45 p.m. that stated the following: Resident R1 cut off her Wanderguard on this shift. When asked where she put it, she said I threw it in the trash can. A new Wanderguard was put on her right ankle. Also found a nail cutter in her pocket. This nurse took the nail cutter from her and put it in the nurse cart. Review of a nurses note for Resident R1 written on 5/6/23, at 8:45 p.m. that stated the following: Resident R1 was found on locked down unit by another nurse. Resident was redirected back to her unit and tolerated the redirection well. Review of a nurses note for Resident R1 written on 5/10/23, at 7:59 a.m. notified by another resident that (Resident R1) had entered her room and taken a pop out of her fridge, entered Resident R1's room and resident was seated on her bed with an opened cold Pepsi on her tray table. Resident R1 denied taking it. Advised Resident R1 not to enter anyone's room and not to take items that didn't belong to her. Advised her she is welcome to buy pop from the vending machine or ask her family to provide them for her. Resident shook her head in understanding. Social Services notified. Police arrived spoke to both parties, no charges were filed. Review of an order written on 5/17/23, to discontinue Wanderguard, and elopement risk was removed from Resident R1's care plan. Review of Resident R1's medical record revealed an additional Wandering Observation Tool completed 5/24/23, that contained the following information: 1) Does resident have a history of wandering and /or a pattern tied to the resident ' s past? Yes 2) Is the resident accepting of current stay/living arrangements? Yes 3) Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave? No 4) Has the resident expressed anxiety/apprehension to leave the facility, packed personal belongings, pacing with no course of action or direction, or attempted to exit doors? No 5) Does the resident have a history of elopement? No 6) Does the resident wander without a sense of purpose? (i.e., confused, may enter others ' rooms, and explore other ' s belongings? Yes 7) Does resident have any additional risk factors for elopement or unsafe wandering? No 8)Based on the responses above, is the resident at risk for elopement or unsafe wandering? No This assessment did not place Resident R1 at risk for elopement or unsafe wandering. Review of a nurses note written on 5/27/23, at 2:40 a.m., that stated the following: Resident R1 returned to [NAME] Health Center at 0225 (2:25 a.m.) this morning. Stated that she is unharmed and feeling okay. VS (vital signs) obtained, and WNL (within normal limits). HS (bedtime) medications were given on arrival. Will continue to monitor. Review of medical record revealed an additional note written on 5/27/23, at 3:59 a.m., stated that following: Resident R1 was brought back to the facility by two [NAME] police officers at about 0225 (2:25 a.m.), ambulatory, escorted back to her room by this nurse. Alert and oriented times three. Not in any distress. Denied any pain. Stated she had a bus pass, walked through the front entrance, and walked to the bus stop where she entered a bus. Family notified of resident's return to the facility. During an interview on 5/31/23, at 10:54 a.m., Resident Representative, Resident Family RF1, recounted the above events and stated that she received a phone call on 5/26/23 at approximately 6:30 p.m. from the Nursing Home Administrator (NHA) informing her that Resident R1 was unable to be located and her whereabouts were unknown. Resident Family RF1 stated that she was told that the police had not yet been notified and she advised that this should be done as the resident has a bus pass. Resident Family RF1 stated that she called the police and that her family conducted a search of their own. Resident R1's son was able locate Resident R1 unaccompanied on 5/27/23, at approximately 1:30 a.m. walking in downtown Pittsburgh (approximately eight miles and 24 minutes by car from the facility). Resident R1's son then took her back to his house. Resident Family RF1 explained that police retrieved Resident R1 at 2:04 a.m. and transported her back to the facility. When Resident Family RF1 was asked if Resident R1 had a history of elopement she stated Yes. At her last facility. She used the code to get out of the door and she said she did it because 'my son needed me . Resident Family RF1 stated that resident often expresses interest in trying to get to her house and car, however she hasn't owned either in many years. During an interview on 5/31/23, at 11:15 a.m., Resident R1 ' s roommate, Resident R2, stated that she was aware of the elopement and had last seen Resident R1 at approximately 2:00 p.m. that day. Resident R2 stated that she (Resident R1) has an alarm but takes it off. She is an escape risk. During an interview on 5/31/23, at 2:35 p.m., Regional Director of Clinical Operations Employee E1 stated that the Corporate Director of Behavioral Programming, Employee E2, had reviewed Resident R1's chart and provided documentation that stated, repeated sexual demands or behaviors may be a person's way of expressing they need intimacy- also maybe an attempt to be freed from a restrained environment. Therefore, the decision was made to discontinue Resident R1's Wanderguard. During an interview on 5/31/23, at 3:04 p.m., Social Worker Employee E3, stated I agree that she (Resident R1) would need supervision with taking a bus and going out of the facility. During an interview on 5/31/23, at 3:24 p.m., Nurse Aide (NA) Employee E4 was asked how she would identify any resident that would be at risk for elopement and NA Employee E4 replied that they have Wanderguards and are in an Elopement Book at the front desk. NA Employee E4 also stated that she was working the evening that Resident R1 was returned to the facility by the police, and she had asked Resident R1 why she had left the building and that Resident R1 replied that she was 'going to Clairton to get my car and see my son.' NA Employee E4 also stated that Resident R1 walks all around the building and that I don't think she can make that decision to be able to leave the building unattended. During an interview on 5/31/23, at 3:26 p.m. NA Employee E5 was asked how she monitors residents at risk for elopement and stated, they have Wanderguards, but that Resident R1's was taken off and that she tries to keep an eye on her, but she walks all over so it's hard. NA Employee E5 stated that she asked Resident R1 where she went the evening of the elopement and Resident R1 stated that she was ' trying to get to Clairton but got on the wrong bus.' NA Employee E5 added that she shouldn't have been out that late. During an interview on 5/31/23, at 3:30 p. m. Resident R1 was asked if the above interviews were accurate, and she said yes. When Resident R1 was asked what kind of car she owned she had stated I don't know. During an observation on 5/31/23, at 3:36 p.m., State Agency noted that no receptionist was at the front desk and attempted to exit out of the front door. However, the door was secured, and egress was not successful. During an interview on 5/31/23, at 3:40 p.m. Receptionist Employee E6 explained that someone is at the front desk from 6:00 a.m. until 8:30 p.m. and that no one can enter or exit the facility without being buzzed in by staff. Receptionist Employee E6 explained she has a button under her desk that once pressed, opens the doors and after 8:30 p.m. she puts a lock box over the button so that it cannot be accessed. Receptionist Employee E6 explained that after she leaves at 8:30 p.m. it is then nursing staff's responsibility to let people in and out of the building. She further explained that there is a keypad at the front door that requires a code. Once the correct code is entered the doors will open. Receptionist Employee E6 also displayed the Elopement Book which is utilized to help her identify residents that have been deemed an elopement risk. The Elopement Book contains Face Sheets of residents that reside on the locked unit and of two people that have Wanderguards. The Face sheet contains a small black and white photo of the resident in the upper left-hand corner of the page. Receptionist Employee E6 stated that Resident R1 was no longer in the book because she no longer had a Wanderguard and does not reside in the locked unit. Receptionist Employee E6 stated she had seen Resident R1 by the front door the day before the elopement and had to redirect her back to her unit. She also stated that she was on duty the evening of the elopement but was unable to explain how resident may have gotten out of the building. Receptionist Employee E6 offered an explanation that Resident R1 may have exited within a larger group of people and was not identified but that it's easy to let them out when they don't have a Wanderguard. On 6/1/23, at 11:29 a.m., the Regional Director of Clinical Operations Employee E1 was made aware that Immediate Jeopardy existed for one of 176 residents, which resulted in an elopement from the facility, and a corrective action plan was requested. During an interview on 6/1/23, at 2:25 p.m. the Regional Director of Operations Employee E9 stated that there was a system failure when a Wandering Assessment was done. On 6/1/23, at 4:32 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -Possible elopement was identified on 5/26/23, by approximately 6:00 p.m., staff had conducted a full accountability census (head count) of all residents, verifying only one resident was not found. A complete search of property interior and exterior had been engaged without success in findings, with repeated searched each hour through 12:30 a.m. on 5/27/23. -Police were contacted at approximately 7:05 p.m. on 5/26/23, reporting a potential elopement. -Allegheny County Port Authority Bus Line was also contacted. -Resident R1 was returned to the facility on 5/27/23 at 2:40 a.m. and assessed by nurse for injuries with no adverse findings. -Staff education was implemented on elopement prevention policy and ways to identify residents at risk for elopement. Education was completed on 6/2/23 at 12:00 p.m. -Specific training provided to front desk individual who let Resident R1 out of the front door, to identify potential elopement risk. Education was completed on 5/31/23. -An Interdisciplinary Team Meeting was held on 6/1/23 to review Resident R1's care plan interventions regarding risk for elopement and care plan adjustments were made and Wanderguard was reapplied. Residents: -A review of all current residents wandering assessments were audited for accuracy and any risk factors identified from these assessments will have care plan interventions to reflect these changes. These were completed by 6/2/23, at 8:45 a.m. System Correction: -System change implemented for changing front door code every month to prevent unwanted egress. -Changed system for receptionist for the wander photo book to incorporate only those residents not on the behavior unit. This will include residents that have access to the front door and have been determined to be at-risk for elopement. Monitoring: -Audit all wander assessment by 6/1/23, then three times per week for five weeks, then five times per month for 3 months. -Audit daily nurse notes for signs and symptoms of wandering behavior each business day (five times per week) for five weeks, then three per week for three months. -Five times a week for two weeks for resident elopement risk with appropriate care plan interventions. The Director of Nursing or designee will audit five staff members five times per week for two weeks then two times a week for two weeks for ability to identify residents at increased risk for elopement. -All audits will be referred to Quality Assurance Performance Improvement (QAPI) committee for review of results and continuation as results indicate. During interviews on 6/2/23, from 9:30 a.m. through 11:30 a.m. 19 employees confirmed they had received education on the new facility elopement policy and procedures, which included identification of exit-seeking behaviors, and interventions to reduce risks. During a medical record review on 6/2/23, it was verified that all residents had received updated wandering assessments. During an interview on 6/2/23, at 10:00 a.m., Licensed Practice Nurse (LPN) Employee E7 stated that she was Resident R1's nurse the evening of the elopement and had also completed the Wandering Observation Tool dated 5/24/23 that marked Resident R1 to not be at risk for wandering or elopement. LPN Employee E7 explained that she was unaware of Resident R1's history of elopement and that when she completed the Wandering Observation Tool, she referred to Resident R1's care plan to see if she had been categorized as a risk for elopement and that the care plan did not contain any interventions for wandering or elopement. She further stated that she was aware that Resident R1 no longer had a Wanderguard and this, along with the care plan information led her to mark that Resident R1 was not at risk for wandering or elopement. LPN Employee E7 stated that she was first aware of Resident R1's absence at 6:00 p.m., as Resident R1 usually stops to see her at that time for her medication. LPN Employee E7 then asked other staff if they had seen her, and the last confirmed sighting had been between 5:00 p.m. and 5:30 p.m. LPN Employee explained that she and other staff members began looking for her and attempted to call Resident R1 on her cell phone, however Resident R1 had left her cell phone in her room. LPN Employee E7 stated that she got in her car and drove around the neighborhood to look for Resident R1 but was unsuccessful. LPN Employee E7 had also notified a nursing supervisor. During an interview on 6/2/23, at 1138 a.m., NA Employee E8 stated that she also was present on the evening of the elopement and assisted in her search. NA Employee E8 stated that she was surprised that she (Resident R1) wasn't on a Wanderguard anymore because she does wander. Why would you take it off? She's always gone. The Immediate Jeopardy was lifted on 6/2/23, at 1:08 p.m. when the action plan implementation was verified. During an interview on 6/2/23, at 1:19 p.m. the Nursing Home Administrator and Regional Director of Clinical Operations Employee E1 confirmed that the facility failed to provide adequate supervision for Resident R1 which resulted in an elopement from the facility. This failure created an immediate jeopardy situation for one of 176 residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.